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Chronic pain after breast cancer surgery


Breast can­cer is the most com­mon can­cer affect­ing women, and surgery – either to the breast and/or the under­arm area – is the main treat­ment. There are two main types of breast oper­a­tion: a mas­tec­to­my (removal of the whole breast) or a lumpec­to­my (removal of the can­cer­ous lump) which is a breast-con­serv­ing surgery. The lymph nodes in the armpit can also be affect­ed and it is com­mon for women to also have a pro­ce­dure for par­tial or com­plete removal of lymph nodes

How com­mon is pain after surgery?

One of the first UK stud­ies of chron­ic pain after mas­tec­to­my was con­duct­ed in Scot­land in 1999. Over 400 women were sur­veyed at three years after their breast can­cer surgery and 43 per cent still report­ed pain in the chest and upper arm. Many women report­ed prob­lems with every­day activ­i­ties, such as lift­ing bags, turn­ing the steer­ing wheel when dri­ving and doing house­hold tasks. For some women, the painful symp­toms had start­ed fair­ly soon after their oper­a­tion; for oth­ers, symp­toms had start­ed lat­er, pos­si­bly relat­ing to radio­ther­a­py and chemother­a­py treatments.

Six years lat­er, the same women report­ing painful symp­toms were resur­veyed to find out whether they had recov­ered. About half of the women with pain at three years were, by then, pain-free; the oth­er half still had pain (on aver­age sev­en to nine years after their mas­tec­to­my). Of those still with pain, the women report­ed that they had ‘learned to live’ with their painful symp­toms – many had tried alter­na­tive therapies.

The researchers then con­duct­ed anoth­er study across Scot­land to under­stand more about the type of pain expe­ri­enced both before and after breast can­cer surgery. They assessed anoth­er 400 women before their breast can­cer oper­a­tion and very few report­ed chron­ic pain in the breast and upper body. After surgery, over half of the women report­ed mod­er­ate- to severe-inten­si­ty acute pain in the first week after surgery. Based on the ‘before’ find­ings, this pain was not a con­tin­u­a­tion of any exist­ing pain. The researchers found that, of the 400 women sur­veyed, those who had more severe acute pain after surgery were more like­ly to have chron­ic pain at four and nine months after their oper­a­tion. This sug­gests that if health­care pro­fes­sion­als could bet­ter con­trol and treat pain imme­di­ate­ly after the oper­a­tion, they may reduce the pro­por­tion of women going on to suf­fer with chron­ic painful symptoms.

Nerve and phan­tom pains

Women with neu­ro­path­ic pain (nerve pain) use terms such as ‘stab­bing’, ‘burn­ing’, ‘tin­gling’, ‘shoot­ing pain’ or ’numb­ness’ to describe their symp­toms. Sur­geons may have to dis­sect branch­es of the main nerve run­ning through the under­arm when remov­ing the tumour and sur­round­ing tis­sue – this is unavoid­able, but may be part­ly respon­si­ble for some symptoms.

Although neu­ro­path­ic pain is the most com­mon type of pain report­ed after breast can­cer surgery, some women also expe­ri­ence phan­tom breast pain. Phan­tom pain is pain that seems to come from an ampu­tat­ed limb, breast or oth­er body part. Phan­tom sen­sa­tions after mas­tec­to­my might not involve pain, but there are reports of 17 per cent of women up to six years after surgery hav­ing phan­tom breast pain.

What are the risk factors?

Cer­tain groups of women may be more at risk from chron­ic pain after their breast surgery than others.

First­ly, younger women do seem to be at greater risk of chron­ic pain than old­er women – this has been found after many dif­fer­ent oper­a­tions. This find­ing might be part­ly explained by the fact that younger peo­ple are often more active and are work­ing, thus hav­ing per­sis­tent pain could have a greater impact on their dai­ly life com­pared to old­er peo­ple who are per­haps less active. Or it may relate to nerve and tis­sue changes (how the body reacts to pain) as we get older.

There is recent evi­dence to show that women with oth­er chron­ic pains are at greater risk of hav­ing chron­ic pain after their breast can­cer surgery. This may include peo­ple who suf­fer from such con­di­tions as chron­ic low back pain, irri­ta­ble bow­el syn­drome, migraine, fibromyal­gia and per­haps sev­er­al oth­er con­di­tions as well. Changes in the ner­vous sys­tem may well lie behind many of these con­di­tions. The field of pain genet­ics has also sug­gest­ed that some peo­ple may be more sus­cep­ti­ble to pain con­di­tions than others.

It is entire­ly expect­ed that women will be wor­ried and fear­ful of their future when faced with a can­cer diag­no­sis and impend­ing surgery. Women who are very anx­ious and wor­ried about their oper­a­tion are at high­er risk of both acute and chron­ic pain after surgery – so exces­sive wor­ry and anx­i­ety is a risk fac­tor. This has been found with oth­er oper­a­tions, not just breast can­cer surgery. It is impor­tant that sup­port and infor­ma­tion are offered to patients to help man­age these feelings.

Pre­op­er­a­tive prepa­ra­tion is vital; for exam­ple, a clear expla­na­tion about the oper­a­tion and recov­ery process set­ting out the risks (and ben­e­fits) should be under­tak­en as stan­dard practice.

Final­ly, one of the strongest and most con­sis­tent risk fac­tors for chron­ic pain after surgery is the sever­i­ty of acute pain in the days and weeks after an oper­a­tion. Treat­ment and ade­quate con­trol of acute pain imme­di­ate­ly after surgery is very impor­tant and may ‘damp­en’ the pain response, pre­vent­ing longer term symp­toms. Again, there is emerg­ing evi­dence to sug­gest that women report­ing pain with neu­ro­path­ic char­ac­ter­is­tics (such as stab­bing, tin­gling and numb­ness) in the ear­ly peri­od after surgery may be at greater risk of hav­ing these symp­toms per­sist in the longer term.

Treat­ment

Long-term pain after breast can­cer surgery is treat­ed in much the same way as oth­er post­sur­gi­cal pain. Some pain-reliev­ing drugs may not be suit­able if women are tak­ing long-term hor­mone treat­ment. Refer to the leaflet ‘Chron­ic Pain after Surgery’ for more details.

Bet­ter understanding

An ear­li­er ver­sion of ‘Chron­ic Pain after Surgery’ report­ed wide­spread mis­di­ag­no­sis of pain after breast surgery. There are now many hun­dreds of arti­cles from around the world report­ing that painful symp­toms after breast can­cer surgery are com­mon, dis­abling and can be chal­leng­ing to treat. More is known about the types of surgery that may increase the risk of post-oper­a­tive chron­ic pain e.g. surgery to remove all the lymph nodes under the arm (axil­la).

Research stud­ies now include larg­er num­bers of patients than the ear­ly sur­veys. One of the largest stud­ies ever con­duct­ed was under­tak­en in Den­mark, where almost every breast can­cer surgery patient in the coun­try was fol­lowed-up two years after their oper­a­tion. The research team found that out of over 3200 women, half still had pain in more than one area relat­ed to their oper­a­tion, and 58 per cent report­ed sen­so­ry dis­tur­bances, such as numb­ness or sen­si­tiv­i­ty to touch. Over­all 25 per cent of women had mod­er­ate to severe pain two years after their surgery. The study also revealed that many women suf­fer­ing symp­toms were under-treat­ed and had poor pain relief and symp­tom con­trol. This was a huge­ly impor­tant study and was pub­lished in the Jour­nal of the Amer­i­can Med­ical Asso­ci­a­tion (JAMA), one of the high­est rank­ing med­ical jour­nals. This pub­li­ca­tion has helped to increase recog­ni­tion and raise aware­ness of the con­di­tion amongst doc­tors and health­care professionals.


Pro­fes­sor Bruce is based at the War­wick Clin­i­cal Tri­als Unit, Uni­ver­si­ty of Warwick.

If you would like to know more about the sources of evi­dence con­sult­ed for this pub­li­ca­tion, please click here.

Chron­ic Pain after Breast Can­cer Surgery © Julie Bruce. All rights reserved. Revised June 2019. To be reviewed June 2022. First pub­lished June 2015.

Comments

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Thank you, have had post bilat­er­al mas­tec­to­my pain for 12 months and was hav­ing trou­ble con­vinc­ing GP!!! Now have ammu­ni­tion with your site which has giv­en me direc­tion to research­ing stud­ies!!! Breast team told me no fund­ing for refer­ral to pain clin­ic had to go via GP!

Suzanne Winterton

Most help­ful; utter relief to read this after expe­ri­enc­ing increased dis­com­fort, pain and numb­ness 9 months after breast and lymph node surgery.

Margaret Spillane

Had a lumpec­to­my 20 years ago and have always suf­fered a cer­tain lev­el of dis­com­fort since in my left breast, which I learned to live with. Now after recent prob­lems with my upper back, I have been doing s suite of physio exer­cis­es to improve my pos­ture and core strength. These seem to have aggra­vat­ed my scar tis­sue and now the dis­com­fort has wors­ened. I have burn­ing and stab­bing sen­sa­tions around my scar. Have had a recent mam­mo­gram which was clear so I’m con­fi­dent that it’s not a recur­rence but where do I go to get some relief? My physio has just giv­en me stretch­ing exer­cis­es that don’t help. Your arti­cle is very inter­est­ing as I had no sup­port for this post surgery.

Hi Mar­garet, we are unable to give med­ical advice at Pain Con­cern, but we would like to direct you to our leaflet on Chron­ic Pain After Surgery (https://painconcern.org.uk/chronic-pain-after-surgery/). Specif­i­cal­ly, the ‘Treat­ment of chron­ic post-surgical
pain’ section.

Comments are closed.

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